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Fluoride Therapy and the Periodontal Patient

 In the general practice, the two most common dental diseases in patients are caries and periodontal disease. Both are infectious, communicable bacterial diseases that can be interrelated. Before any care—including prophylaxis—is initiated clinically, each patient must be diagnosed, informed of his or her current status, and offered options for appropriate care [Table 1]. Current standards of care dictate a thorough review of the patient’s health status at the beginning of the visit, along with the preparation of updated diagnostic radiographs and a complete periodontal chart needed to formulate the dental hygiene diagnosis. 

Between 75 and 85% of all adults have experienced some degree of periodontal disease, including gingivitis.1 Since periodontal disease is a chronic, bacterial infectious disease, it presents an ongoing challenge to the clinician to monitor, treat, provide follow-up care, and manage patient behaviors affecting the progression and management of this disease.             

Patients who suffer from periodontal disease eventually show signs of gingival recession and, oftentimes, hypersensitivity. Recession can occur as a function of the destructive process of periodontitis, or following surgical or nonsurgical treatment. Many patients also show signs of recession and abrasion due to improper oral hygiene practices. While research has revealed a reduction in the level of periodontal pathogens following periodontal therapy, the levels of the bacteria responsible for caries (streptococcus mutans) have been shown to rise following treatment. This can lead to an increased number of root caries in periodontal patients. It is important to understand the relationship of bacteria in the oral cavity and periodontal disease, and to be aware of the need to incorporate a strong caries-prevention program into periodontal therapy protocols.2

Fluoride therapy is recommended after periodontal debridement (scaling and root planing) to prevent root caries initiation. Exposed root surfaces are softer than enamel, and are not meant to be exposed to the onslaught of acids produced by the interaction of fermentable carbohydrates and the bacteria in plaque. As our population ages, many adults now keep their natural dentition well into old age—often for the duration of their lifetimes. It is important to be aware of the factors that will affect adult patients as they age. Factors to consider include xerostomia, limited dexterity, failing eyesight, poor oral hygiene, illness, or injury, in addition to the use of medications and the need for periodontal surgery. The risk factors involved must continually be evaluated, and treatment recommendations must be made appropriately. Preventive therapy is less invasive and less traumatic than continual dental repair and reconstruction, and is less costly to the patient.

(Continued from page 1 )

Education is an ongoing process and is essential to the management of the patient over the course of treatment, follow-up care, and periodontal maintenance. Patients need to know the benefits of both professional and self-applied fluoride therapies. Often, both patients and professionals may feel that if the teeth are not sensitive, there is no reason to treat the dentition with fluoride. Many patients stop using fluoride products at home once the sensitivity has subsided, not understanding the long-term benefits of strengthening root surfaces to reduce the likelihood of future caries. 

Root caries is a significant issue for the aging and adult periodontal patient. By the age of 50, 50% of adults have experienced root caries.3 The progression of root caries lesions is 2.5 times as rapid as coronal enamel caries.4  An aggressive program of homecare fluoride application in combination with professional treatments can maintain the periodontal patient in a caries-free state.3 Since root surfaces are more porous than enamel, they allow for a higher uptake of topical fluoride. It has been proven, however, that 91% of root caries can be arrested by proper use of topical fluoride.5 For high-risk cases, a combination of chlorhexidine rinse therapy in addition to fluoride therapy can help reduce the bacterial challenge of the high-risk patient susceptible to root caries. 5

Fluoride works by inhibiting demineralization and by enhancing remineralization of the enamel and dentin. Remineralization requires higher concentrations and more frequent application of fluoride than does caries prevention. Fluoride varnishes have proven to be very effective in this application—in vitro studies have shown varnishes to reduce enamel demineralization 50% over nontreated controls.6 Fluoride varnishes are easy to apply, especially with a brush and predosed applications.6 Varnishes do not require drying of the surface, which is beneficial to the sensitive patient, and provide time release of the fluoride ion, which improves the effective net dosage to the area. Desensitizing root surfaces following periodontal debridement procedures can replenish the natural fluoride layer removed by therapy. Desensitizing agents are applied with a cotton pellet and pliers and are burnished into root surfaces after being air-dried and isolated by cotton rolls for one minute. The proactive treatment of vulnerable areas with a loading dose of fluoride can counteract the initiation of root caries following periodontal debridement as well as calm patient fears or complaints of sensitivity.  

Patients suffering from xerostomia require appropriate interventive fluoride treatment. Currently, the Physicians Desk Reference has identified over 500 medications that potentially cause xerostomia. It is essential to monitor health histories and medications for multiple reasons, including the need for preventive fluoride therapy. Since saliva is the natural defense system of the oral cavity and fluoride is one of the components of saliva, the oral cavity will suffer when a reduced level of saliva is available to help neutralize the acids formed. To keep oral tissues moist and reduce the occurrence and risk of infection, specially formulated rinses should be recommended.

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Hypersensitivity can be caused by root exposure, bruxism, whitening agents, tartar-control agents, and alcohol-containing rinses. Topical fluorides can greatly improve patient comfort levels. It is important to communicate to patients the benefits of prescribed fluoride products since insurance does not often provide coverage for these medications. Fluorides are not for children only; they provide valuable benefits to patients throughout a lifetime of changing dental needs. 

The fluoride treatment plan should be based upon a fluoride risk assessment, and recommendations should be based upon need rather than age or reimbursement method. As always when working with patients, education, motivation, and benefits must be continually reviewed for treatment success. Predictably, patients will go through periods of lapse, relapse, and collapse with many of the recommended treatment plans. One of the most challenging job responsibilities is to affect the behavior of patients, which ultimately has an impact on treatment outcomes. 

All patients deserve to be caries-free and comfortable throughout life. Both professional and homecare fluoride products can greatly improve the chances of successful caries reduction and prevention.

 

 *President of PerioAdvocates, a dental hygiene consulting company based in Fairfax, VA. 

References

  1. Oliver RC, Brown LJ, Loe H. Periodontal diseases in the US population. J Periodontol 1998; 69(2):269-278.
  2. O’Hehir T. Root caries risk after periodontal therapy. RDH 1999;(12):10.
  3. Mallatt ME. Preventive strategies for the older dental patient. J Ind Dent Assoc 1997-1998;76(4): 44-49.
  4. Hoppenbrowers PM, Driessens FC, Borggreven JM. The mineral soluability of human tooth roots. Arch Oral Biol 1978;32(5):319-322 and Shay K. Root caries in the elderly: an update for the next century. J Indiana Dent Assoc 1997-1998;76 (4): 37-43.
  5. Carberry FJ. A practical guide to adult caries risk assessment and fluoride use. Compend Cont Educ Oral Hyg 2001;18(1):13.
  6. Todd M. Effect of fluoride varnish on demineralization adjacent to ortho brackets. Am J Orthod Dentofacial Orthop 2002;116(2):163.
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